2013 PhD Commencement Preparation & Information Form

Graduate Information

Name*

PrefixFirstLastSuffix

BU Email*

Other Email

Cell Phone*

Other Phone

Degree Program*

Degree to be Awarded*

PhD
MD
MD/PhD

Dissertation Title*

Name of PI for Dissertation*

FirstLast

Did you receive any awards, Fellowships, or grant funding while at BUSM?*

Yes
No

Please list the awards, fellowships, and/or grant funding, as well as the year received:*

Example: Russek Day, 2007

What are your immediate plans after graduation?*

Postdoc
Medical Residency
Industry Position
Other

Where?

Please Describe:

Position/Title:

Name Withholding Information: Would you like your name, degree information, and awards published in the BUSM graduation program and BU Redbook?*

Yes
No

Please be advised if you choose NO - your degree, academic record or general information will not be released from BUSM to anyone including future employers. You must also update Student Link to reflect this choice.

Commencement Attendance

Will you attend the BUSM Commencement ceremony for Ph.D., M.D./Ph.D., and M.D. graduates on Saturday, May 18th at 10:00 AM at Agganis Arena?*

Yes
No

Phonetic Pronunciation of Name*

How many guests will be attending the commencement ceremony and reception?*

Each graduate is allowed up to 10 guests.

Will you have guests who require disability considerations at the commencement ceremony and/or reception?*

Yes
No

Please decribe special accomodation needed:*

Who would you like to hood you in the commencement ceremony?*

Faculty member
Alternate hooder

Name*

FirstLast

Degree*

PhD
MD
MD/PhD

Relationship*

Degree*

Family members may serve as your hooder provided they must have a Ph.D. or M.D. degree AND wear regalia. Please be sure to ask faculty if he/she will be attending commencement and if he/she has ordered their regalia.

Commencement Picture Dispersal Form

BUSM works with Commencement Photos, Inc. to take photos of our graduates as they receive their diploma. The photographer will mail proofs to you in June to the address you indicate below.

I grant Boston University School of Medicine permission to use any photos taken at Commencement to be posted on the BUMC website or in any BUMC publications.*

Yes
No

After June 1, 2013, my commencement photos should be sent to:*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Questions?

For any questions, please contact: Caitlin Sleasman, sleasman@bu.edu, 617-638-5123